When the carotid artery becomes occluded by atherosclerotic plaques such that a narrowing, or stenosis, is observed, a patient is diagnosed with carotid artery disease. Carotid artery stenosis (CAS) can lead to many neurological conditions including dizziness, numbness, confusion and ultimately stroke. Whether to remove the stenoic plaque surgically, or use a carotid stent has been widely debated; a symposium at the AHA's Scientific Sessions discussed the safety of carotid stents and when they should be used.

“It is important to note,” says William Gray, MD, Associate Professor of Clinical Medicine at Columbia University, “that there are no data comparing the natural history or medical therapies to carotid stenting…period.” Therefore, in order to compare carotid stenting to other procedures, some extrapolations must be made.

The CAPTURE (Carotid RX ACCULINK/RX ACCUNET Post-Approval Trial to Uncover Unanticipated or Rare Events) trial, a post-market study that had 100% neurological event follow-up led by Dr. Gray, was designed to determine if carotid stenting is a safe alternative to surgery in asymptomatic patients. Data was collected from 2,500 patients from 188 medical centers who were at high risk for surgery. The study found that 94.3% of asymptomatic patients were free from major complications (death, stroke or MI) after 30 days, which is higher than numbers reported previously from surgical trials. Octogenarians had the highest event rates at 8.9%, whereas younger patient event rates were almost halved at 4.8%. Low volume operators appeared to have similar results to high volume operators and safety was more dependent on the appropriate case selection.

To increase the odds of a successful procedure, Dr. Gray recommends the following strategies:

• Pre-procedure: acetylsalicylic acid and thieneopyridine

• Intra-procedure: anticoagulation therapy

• Post-procedure: discontinue anticoagulant therapy, continue antiplatelet therapy

• For the management of carotid body stimulation, early ambulation appears to be important

For stroke prevention in carotid stenting procedures, Dr. Gray emphasizes the following;

• Appropriate patient/lesion selection (type III arches, and retroflexed LCCAs are probably not good candidates for stenting due to decreased anatomical access)

• Use of appropriate anticoagulant

• Careful access technique

• Adequate embolic protection (when patients were predilated without embolic protection, the risk of experiencing an event increased)

Given the right patient and the right operator, this minimally invasive procedure could improve outcomes in patients with CAS.